Rhona Maclean

Transcription

1 An early evaluation of the impact of the North Trent policy regarding the use of Non-Vitamin K antagonists for SPAF in a secondary care anticoagulation clinic Rhona Maclean Rhona.maclean@sth.nhs.uk

2 Risk of adverse events in patients with atrial fibrillation taking warfarin Optimal level of oral anticoagulant therapy Torn M et al, Arch Int Med 2009; 169:

3 Unstable Warfarin Anticoagulation INR Results /09/ /10/ /11/ /12/ /01/ /02/2007 Dosage /09/ /10/ /11/ /12/ /01/ /02/ year old woman on warfarin for recurrent VTE INR 3.5

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8 Improving the health outcomes in patients with AF Not on warfarin: high CHADS 2 risk Not on warfarin: unable to tolerate, intermediate CHADS 2 On warfarin anticoagulation, poor time in therapeutic range Stably anticoagulated on warfarin Low CHADS 2 risk on no anticoagulant therapy

9 QoF New Indicators 2012/13 The percentage of patients with atrial fibrillation in whom stroke risk has been assessed using the CHADS2 risk stratification scoring system in the preceding 15 months (excluding those whose previous CHADS2 score is greater than 1) In those patients with atrial fibrillation in whom there is a record of a CHADS2 score of 1 (latest in the preceding 15 months), the percentage of patients who are currently treated with anti-coagulation drug therapy or anti-platelet therapy. In those patients with atrial fibrillation whose latest record of a CHADS2 score is greater than 1, the percentage of patients who are currently treated with anti-coagulation therapy

10 New data Drivers for change in AF anticoagulation Studies demonstrating benefit of anticoagulation in elderly patients with AF New targets QoF New technology New drugs

11 Sheffield Teaching Hospital Anticoagulant Clinic Approximately 3000 patients on oral anticoagulants (mostly warfarin) managed by the clinic +/- 140 new patients/month initiated on warfarin 75% of Sheffield primary care anticoagulation monitoring (<10% offer induction) Patients therefore are started on warfarin by clinic, transferred out to primary care when stable Most patients come to hospital for phlebotomy-postal service with INR result Limited community phlebotomy available-not offered by primary care

12 Clinic patient characteristics >1260 maintenance patients have AF Approximately 400 AFnpatientshave community phlebotomy AF patients aged between 24 and 97 years of age TTR 20%-100% Number of visits in 6 months 2 (100% TTR) 23 (34% TTR) 243 had 10 INR checks within 6 months (26 weeks)

13 My predictions on impact on clinic of NORCOM guidance Most patients with AF will continue to be offered warfarin anticoagulation Clinic numbers will continue to grow due to QoFchanges/ demographics Patients intolerant/ unstable/ unable to follow instructions will be reassessed and considered for a switch to NOAC Proportion of patients will be unsuitable for anticoagulation Proportion of patients would benefit from a switch Increased quality of anticoagulation Fall in stroke/ systemic embolisation

14 Impact of NORCOM Guideline Increased numbers of advice only referrals to haematology regarding suitability of NOACs for individual patients (younger/ well informed/ CHADS2 score 1) 8 anticoagulation clinic patients with AF switched to NOACs 6 STH anticoagulation clinic patients were on phenindione 2 others referred from GPs for assessment and nothing else!... Haematologists using NOACs more widely in patients with VTE

15 Why has little happened? STH issues: NORCOM only issued guidance mid/end June Last minute, little time to work up strategy within organisation DAWN v7 upgrade end July Summer holidays Anticoagulation Service structure INR dosing service Patients not seen by anticoagulant practitioners (but there is a sense of ownership ) Commissioning Commissioners don t want to pay any more for the service to develop..

16 Why has little happened? Primary care issues: NHS reorganisation Trying to role out large changes in practice in primary care very challenging Primary Care Clinician Anxiety Unfamiliar new medication. Anxiety about bleeding with anticoagulants. What is the right thing to do. Education gap Finance NOACs more expensive Commissioners don t want to pay for new services or develop existing pathways Pathways need changing Who will identify patients who should be considered for a switch? Who will assess patient, determine suitability, counsel patient and switch? Visibility of Patients Most AF patients not seen regularly by secondary care specialist QoF will influence patient visibility to primary care clinicians

17 Strategy for maintenance patients with AF Patients attending STH clinic Their GPs usually do not manage anticoagulant therapy STH Clinic will identify patients with AF who could potentially benefit from NOAC and inform their GPs Poor TTR High INRs, low INRs, frequent INR checks Review all patient records or opportunistic identification? Clinic offer to see patients and manage a switch? Provide GPs with advice on assessment Rivaroxaban tick sheet

18 Future pathway? Counsel patients when starting warfarin that if do not stabilise/ intolerant will switch to NOAC? Who will undertake review? GP? With anticoagulant clinic generated report? Anticoagulant clinic? Commissioning issues Anticoagulant clinic paid 20 per INR check and dosing instruction-if they provide patient review and undertake switch to NOAC will be out of pocket.

19 The ideal pathway? Should meet the needs of the patient population Predominantly elderly Trial of warfarin? Initiated and monitored by staff with the relevant competencies, in an environment suitable to the patient Assessment as to tolerance/ stability of warfarin At 3 or 6 months? Manage a switch if intolerant/ unstable If switched Primary care to take on chronic disease management? Care of the elderly role? Anticoagulation clinic? If remains on warfarin- needs monitoring and annual review If becomes unstable, should be considered for a switch

20 Conclusions In the 3 months since the NORCOM guidance has been published: the NOACs have made next to no impact on patients with AF attending the STH anticoagulant clinic Steps have been taken to identify patients who should be considered for a switch, and GPs are to be notified Role of STH clinic in this is dependent on commissioning arrangements